title: Location of lymph node involvement in patients with esophageal adenocarcinoma predicts survival.
abstract: BACKGROUND
  The location of positive lymph nodes has been abandoned in the seventh classification of the TNM staging system for esophageal adenocarcinoma. The present study evaluates whether distribution of involved nodes relative to the diaphragm in addition to TNM 7 further refines prediction.
  
  
  METHODS
  Pathology reports of patients who underwent esophagectomy between 2000 and 2008 for adenocarcinoma of the esophagus were reviewed and staging was performed according to the seventh UICC-AJCC staging system. In addition, lymph node involvement of nodal stations above and below the diaphragm was investigated by endoscopic ultrasonography (EUS) in a separate cohort of patients who were scheduled for esophagectomy between 2008 and 2009 at two institutions. Survival was calculated by the Kaplan-Meier method, and multivariate analysis was performed with a Cox regression model.
  
  
  RESULTS
  Some 327 patients who had undergone esophagectomy for cancer were included. Multivariate analysis revealed that patients with from three to six involved lymph nodes in the resection specimen on both sides of the diaphragm had a twofold higher chance of dying compared to patients with the same number of involved lymph nodes on one side of the diaphragm. EUS assessment of lymph node metastases relative to the diaphragm in 102 patients showed that nodal involvement on both sides of the diaphragm was associated with worse survival than when nodes on one side or no nodes are involved [HR (95 % CI) 2.38 (1.15-4.90)].
  
  
  CONCLUSIONS
  A combined staging system that incorporates distribution of lymph nodes relative to the diaphragm refines prognostication after esophagectomy as assessed in the resected specimen and pretreatment as assessed by EUS. This improved staging has the potential to have a great impact on clinical decision making as to whether to embark upon potentially curative or palliative treatments.
authors.affiliation: Department of Surgery, Erasmus Medical Center, Room H-828, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands, koentalsma@hotmail.com.
authors.forename: Aaldert K
authors.initials: AK
authors.lastname: Talsma
authors.forename: Chin-Ann J
authors.initials: CA
authors.lastname: Ong
authors.forename: Xinxue
authors.initials: X
authors.lastname: Liu
authors.forename: Pieter
authors.initials: P
authors.lastname: van Hagen
authors.forename: Jan J B
authors.initials: JJ
authors.lastname: Van Lanschot
authors.forename: Huug W
authors.initials: HW
authors.lastname: Tilanus
authors.forename: Richard H
authors.initials: RH
authors.lastname: Hardwick
authors.forename: Nicholas R
authors.initials: NR
authors.lastname: Carroll
authors.forename: Manon C W
authors.initials: MC
authors.lastname: Spaander
authors.forename: Rebecca C
authors.initials: RC
authors.lastname: Fitzgerald
authors.forename: Bas P L
authors.initials: BP
authors.lastname: Wijnhoven
mesh_terms: D000230:Adenocarcinoma / Q000401:mortality* / Q000473:pathology* / Q000601:surgery; D004938:Esophageal Neoplasms / Q000401:mortality* / Q000473:pathology* / Q000601:surgery; D016629:Esophagectomy; D005260:Female; D006801:Humans; D008207:Lymphatic Metastasis / Q000473:pathology; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D011379:Prognosis; D012189:Retrospective Studies; D015996:Survival Rate